Peripheral arterial disease predicts mortality in TAVI patients

By Andrew Czyzewski

Patients with severe aortic stenosis who undergo transcatheter aortic valve implantation (TAVI) are at particularly high risk for complications and death if they also have concomitant peripheral arterial disease (PAD), study results show.

Importantly, choosing a surgical, rather than transfemoral, access strategy did not mitigate the risk associated with PAD, Georg Nickenig (Universitatsklinikum, Bonn, Germany) and colleagues report.

TAVI has expanded the treatment options for severe, symptomatic aortic stenosis in patients at high risk for surgical aortic valve implantation, but several procedure-related drawbacks have been identified.

Notably, the prevalence of PAD in patients with TAVI has been reported to be 20% to 30%.

"The objectives of this study were, therefore, to determine the impact of PAD on clinical outcome after TAVI in a real-world setting and to assess whether this risk can be mitigated by electing a different access site," Nickenig et al comment in the American Heart Journal.

The study included 1315 patients with severe aortic stenosis who underwent TAVI in 27 centers and were included in the prospective German TAVI Registry.

Of these procedures, 1143 (86.9%) were done via the transfemoral, 121 (9.2%) by the transapical, and 41 (3.1%) by the transsubclavian route; as well as 10 (0.8%) via transaortic access.

In all, 330 (25.1%) patients had PAD and these patients had a higher logistic European System for Cardiac Operative Risk Evaluation score than their peers without PAD (27.7 vs 18.3%), mainly attributed to having more frequent and severe comorbidities.

Patients with PAD had a higher rate of vascular complications compared with patients without PAD, (28.5 vs 20.7%), dialysis-dependent renal failure (11.2 vs 5.4%), myocardial infarction (1.2 vs 0.3%), and, subsequently, 30-day mortality.

Interestingly, the prevalence of PAD was 59.3% in patients undergoing TAVI with surgical access compared with just 19.9% in patients who underwent full percutaneous transfemoral access, suggesting that some site selection was based on risk.

However, choosing a surgical approach, for example, transapical access, did not reduce the periprocedural risk associated with PAD. Indeed, in-hospital mortality was 15.7% for a surgical route and 10.5% for full percutaneous access among those with PAD.

Finally, in a multivariate regression analysis, PAD was an independent predictor of 30-day mortality after TAVI (hazard ratio=1.8).

Discussing the findings, Nickenig et al comment: "Based on the presented data, one may consider rejecting very-high-risk patients with PAD.

"However, survival in patients with PAD who have severe aortic stenosis and who do not undergo TAVI would be even worse."

Ultimately they say that further technologic developments are required to reduce the vascular complication rate in patients with PAD.

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